I am the CEO of patient relationship management company Avado (acquired by WebMD October 2013), the first cloud-based EHR-agnostic patient portal. I was named one of the 10 most influential people in healthIT and a "healthcare transformer" by the StartUp Health Academy. I have been invited to the White House and presented before the head of Medicare and the Pioneer ACOs. I'm also a co-editor and writer of a book commissioned by HIMSS on patient engagement. Previously, I was a senior consultant in Accenture's healthcare practice and a founder of Microsoft's $2 billion health platform business. I left Microsoft in 2003 to work in startups as an executive to multiple high growth companies. Avado has been featured in the New York Times, Wall Street Journal, TechCrunch, Washington Post, Bloomberg and numerous healthcare industry publications. It partners with EHR vendors to provide a competitive advantage over silo'ed patient portals and was selected by 22 pioneering healthcare providers in New York state for a statewide program pioneering accountable models.

Patient Engagement is the Blockbuster Drug of the Century

The insight of the year goes to Leonard Kish, a health IT strategy consultant, for making that statement regarding patient engagement. The corollary to this statement is a game changer: What happens when effective patient engagement becomes the Standard of Care?

Used to determine whether a doctor is liable for medical malpractice. The standard of care is important because it determines the level of negligence required to state a valid cause of action.

It’s hard to overstate the implications of doctors being held to the Standard of Care. Many argue that the basis of unnecessary and duplicate procedures is the fear of malpractice. Doctors understand that in a malpractice case one of the key items that is analyzed is whether they met the Standard of Care. [Otwebhers argue that the "do more, bill more" reimbursement model has been at least as big of a driver. Regardless, malpractice concerns related to the Standard of Care are a big driver] [Disclosure: My patient relationship management company, Avado, works with some of the companies/individuals mentioned in this article which is why I'm familiar with their work.]Comparing Two Blockbusters Kish compares the statins blockbuster with the patient engagement “blockbuster”. [See Kish's full article here.]

First, the evidence for blockbuster drugs. In Dr. Eric Topol’s book “The Creative Destruction of Medicine,” he takes a deep look at the evidence for statins, possibly the biggest group of blockbuster drugs over the last 20 years. Statins are a requirement of Meaningful Use Stage 1 clinical quality measures, as well as key measures for the CMS hospital quality measures used by many organizations, internal and external to the hospital, to grade the quality of care at a hospital. Prescribing statins, in many instances, is no longer optional. Topol states that “of every 100 patients taking Lipitor to prevent a heart attack one patient was helped, 99 were not.” These drugs cost $4 per day per patient and $1500 per year. While they are great at lowering cholesterol, it remains unclear that they do much to prevent heart attacks. Now let’s take a look at a 2009 Kaiser study of coordinated cardiac care. Compared to those not enrolled in the study, coordinated care “patients have an 88 percent reduced risk of dying of a cardiac-related cause when enrolled within 90 days of a heart attack, compared to those not in the program.” And, “clinical care teams reduced overall mortality by 76 percent and cardiac mortality by 73 percent.”

Kish goes on to share another example from the VA that shows similarly astounding results and then asks the salient question.

Can you imagine if a drug reduced the need to go to the hospital by this amount? Again, it would be considered malpractice not to use it.

Expecting Restauranteurs to Teach Their Patrons How to Cook Kish states the expected pushback from healthcare providers when they are held accountable for their patient’s actions.

All this is so different for healthcare providers. It’s like a great restaurant learning that their new business is going to be – in addition to continuing to provide a great in-restaurant experience – teaching people how to cook at home. What? This isn’t what we do! It’s impossible!

While this is an understandable perspective for them to have given that they haven’t been accountable for their patients’ actions, I think clinicians underestimate their own influence. Consider that Gallup’s recent ranking of the most trusted professions are as follows:

Nurses

Pharmacists

Doctors

Clinicians may not think in these terms but consider some of the less-than-pleasant things they regularly convince patients to endure based on the trust we place in them. Whether it’s something that is life-threatening or not, doctors have proven to be persuasive. As I outlined in Doctors Success Hinges on Transactor to Teacher Transition, the root of the word doctor is teacher and it is through instruction of their patients that people are willing to deal with various disagreeable or unusual items such as the following:

We strip ourselves bare literally and figuratively with our care teams in a way we don’t with anyone else in our lives, with the exception of our closest loved ones.

Oncologists convince their patients to endure chemotherapy with its well-known side effects of going bald and extreme nausea.

Listen to just about any pharmaceutical advertisement to hear some nasty side effects — some are quite common.

Surgeon’s regularly convince obese patients to staple part of one’s stomach (bariatric surgery) where studies have shown 1% of patients die and 40% have complications.

When I worked in an OR, the nurses sensitized me to the significant risks of anesthesia yet most don’t question their doctor if they are told they are going to be put under for a surgery.

Caesarean Sections: The rate has gone up more than 50% in the last 15 years for a whole host of reasons. Clearly doctors have influenced that whether it’s for outcomes or malpractice reasons. Women are well aware of a longer recovery time, scars and other side effects but trust their doctor’s judgment.

Surgeons have convinced their patients to inject botulinum toxin (aka Botox) into the face of a patient on a regular basis. As Wikipedia states, “botulinum toxin can cause botulism, a serious and life-threatening illness in humans and animals.”

The efficacy of the items above are impacted by patients after they leave the clinic/hospital. The key reason doctors, nurses and pharmacists are able to persuade is their trust and credibility. Not only are clinicians trusted, most of us remember their classmates who went into medical careers as some of the smartest people they grew up with. If that smart, trusted individual recommends using a patient-facing tool, it’s a slam dunk that the vast majority of patients will respond (some may need more explanation than others — just as the above interventions would). Success Goes to the Behavioral Scientists Doctors are human. As I’ve heard said, “if you want to understand a sales person’s behavior, study their commission plan. If you want to understand a doctor’s behavior, understand their reimbursement model.” As Kish stated, “It’s no accident that in both the examples here (Kaiser and the VA), the providers and the payers were tightly aligned, because the economics have to be aligned before any of this will work.” At the root of the success of the Direct Primary Care organizations I have written about before who are the “Triple Aim” (lower cost, improve the patient experience and improve outcomes) champs is their understanding of criticality of building trust. It simply isn’t possible in a 7 minute “drive-by” appointment so common today. As in any relationship, trust is built on a firm foundation of communication. Read more on communication being the medical instrument of the future.

If you would like to be notified when the seminal paper on Direct Primary Care is published this Fall, please contact me via my LinkedIn profile – http://www.linkedin.com/in/chasedave. The related insight is recognition that it’s going to be impossible to succeed in a value and outcome based reimbursement model if the provider doesn’t recognize that 75% of healthcare spending is on chronic disease. The majority of decisions that most influence outcome are made by patients and their families — not clinicians. This is expanded upon in Health Systems Ignore Patients at their Own Peril. It’s particularly true in primary care which is why IBM has catalyzed primary care by changing how it buys healthcare. However, it’s not limited to primary care. Two healthtech startup colleagues of mine are Eric Page and Russell Benaroya who previously owned sleep centers. While the industry benchmark for adherence to CPAP therapy programs was 40%, they achieve 79%. They have shared that their “secret” was building trust using techniques that are commonplace for consumer marketers. Much of that revolved around creating an emotional connection with their organization via their team members. Consumer marketers, for better or worse, understand how to change behavior. If they didn’t, we wouldn’t have any of these fashion or food choices. An example of where the consumer marketer mindset must take hold was highlighted by the pioneer healthcare organizations who shared lessons learned. In a nutshell, proactive communication is the “inoculation’ to biggest fears these organizations have — system leakage (i.e., patients getting care outside of their network). If the organization isn’t top-of-mind at their patient’s moment of truth when some medical need arises, it’s guaranteed they’ll have significant system leakage. This is a disaster for organizations given a block of money to care for patients and then they have to pay a third-party health system for the services that those patients received when they “leaked” outside of the system. What Comes NextNext After Blockbuster Drug Marketing?Matthew Herper wrote last year that The Blockbuster Drug Comes to an End. For the fourth consecutive year, pharmaceutical advertising declined in 2011. Not surprising since between 2007 and 2012, drugs worth some $63 billion in sales lost market exclusivity. And between 2011 and 2015, the New York Times says, the total is $100 billion. Any business dependent on blockbuster drug marketing has taken a big hit with no end in sight. Now imagine that the blockbuster “drug” is patient engagement. Already we have seen organizations such as Jenny Craig, Weight Watchers and online sites such as eDiets increasing their advertising. After all, managing one’s weight is a form of patient engagement. As patient engagement programs such as managing high blood pressure prove themselves, it’s only a matter of time before prime time TV and health websites are filled with advertising that seeks to engage groups of patients in healthy behaviors. Online media properties are particularly well positioned as they can target consumers based on attributes including what company they work for. It’s not hard to imagine General MotorsGeneral Motors or other large employers targeting ads to their employees while they are on WebMD or Yahoo Health. Rather than ad sales reps calling on the marketing department, they will start calling on the HR/benefits department. Who knows, they may start calling on the Finance/Investor Relations department. When public companies such as Safeway have demonstrated they can reverse healthcare hyperinflation, other public companies will find that a cost as significant as healthcare that is unmanaged is a dereliction of fiduciary responsibility. Highly targeted Internet advertising may prove they can have a material impact on getting employees engaged in their health. While some providers have had so-called “patient portals” they have largely focused on administrative functions. I’d argue that the top 3 most popular “patient portals” are Google, WebMD and Wikipedia. While providers fret about the perceived challenge of engaging patients, as Steve Wilkins outlines, patients are already very engaged. After email and search, consuming health information is one of the most popular activities on the web. Perhaps it’s that the patient portals from vendors focused elsewhere (ICD-10, billing, etc.), aren’t well suited to develop patient facing tools. While companies like SAP are pivotal for large organizations, those same organizations don’t rely on SAP for consumer-facing solutions. I predict that the EHR patient portals will eventually give way to solutions from consumer-focused companies as the business case for patient engagement becomes more understood. Once upon a time, search was an afterthought on web portals such as MSN and AOL as there wasn’t a business case for search. Clearly, Google has proven that wrong.Med School Wasn’t Easy Either There are 3 trillion reasons why healthcare has to change but also 3 trillion reasons why incumbent organizations are resistant to change. After all, one person’s cost savings are another’s revenue. The government has sent a shot across the bow of healthcare providers with the strings attached to Medicare reimbursement. In addition, the federal stimulus dollars driving the adoption of electronic medical records has been tied with the demonstration of “Meaningful use”. The second tranche of dollars is tied to requirements that were recently rolled out. The item that received the most pushback related to demonstrating patient engagement. The American Hospital Association came out strongly against these requirements. In response, the government lowered the requirement from 10% to 5%.

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Thank you for this informative article. I have worked for over a decade in patient education and engagement efforts and have no doubt that patient engagement is an invaluable tool that is often overlooked in our quest for health care safety and quality. Our website at www.EmpoweredPatientCoalition.org offers many free patient education/engagement tools including a Hospital Guide, Patient Journal, fact sheets, checklists, and others. We have to spend the time and effort to lay the foundation and build the infrastructure of patient engagement – which begins with a small amount of information, support, and confidence.

The challenge for providers regarding patient engagement is not so much how to engage patients in their own care…but rather how to be engaging to patient who are already engaged.

The simple act of a trip to the doctor’s office is a good example. Before a person shows up at the doctor’s office they have to 1) have a reason or need (symptoms, a concern, chronic condition), 2) they have to believe that the need or reason merits seeing the doctor vs. taking care of it at home themselves – this generally implies cognition and doing research, i.e., talking with friends, going on line, etc, 3) making the appointment (by calling or going online and 4) showing up for the appointment, and 5) thinking about what they want to say to the doctor.

Now providers tend to not consider the patient’s perspective when it comes to engagement. For most providers, i.e. physicians and hospitals, engagement means getting patients to do what providers say is in their best interest…what I say is right. But that approach totally dismisses the fact that, as I have shown, that patients are already engaged…just not in the same way that providers expect.

How “engaged” would readers here find it if they went to their doctor only to have the doctor 1) not ask why they are there (fears and concerns) or worse yet ignore the fears and concerns which they describe to the doctor, 2) disagree with the doctor as to the visit priority and how to diagnose and treat it, including for example being prescribed medication when you don’t want to take pills or 3) found out that you knew more about your problem and how to deal with it than your doctor?

The point is that providers need to be engaging to patients in the demeanor, attitudes and how they talk with and listen to patients. Doctors need to know who the patient is, what their fears, concerns and expectations are and what the patient is able and will to do.

Fundamentally patient engagement is not a HIT or technology challenge but a human relations and communications challenge. It’s great that HIMSS is interested in the subject…HIT can help but what is really needed is more focus on helping physicians develop patient-centered communications not but more technology between themselves and their patients.

For more information on patient engagement, check of my white paper on Patient Engagement in Primary Care on my blog Mind the Gap at www.healthecommunications.wordpress.com.

Yes, well said Steve. Re: “engagement is not a HIT or technology challenge but a human relations and communications challenge.” True enough, but as technologies mature, they fade into the background. Talking to your doctor your cell phone wouldn’t be considered a communications challenge, because the technology has become so transparent that you hardly notice it (unless it doesn’t work). In HIT and social media (really just new communications technologies), the technology is still very much in the foreground, but this will change, and the level of communication will become deeper. It’s a dimensional shift as physicians can start to “see” more of their patients through the data the collect.

It is an HIT challenge to a) move the communications into the background and make them transparent, but also, with limited primary care resources, to b) allow those communications to scale.

Scalable communications that allow for scalable learning (for both doctor and patient) are where effective patient communications and patient engagement will go.

Nice Dave. Speaking of direct practice and Qliance in particular, take a look at Rob Lamberts, MD “Dropping Out’ piece on The Healthcare Blog including excellent commentary, where I correct some ACA misinformation via a quote Garrison Bliss, MD on the eligibility of DPC models for listing on health insurance exchanges:

Thanks for the heads-up on Rob’s piece. I have been in touch with him and applaud his big move.

For others interested in the DPC model (there are various misconceptions), feel free to connect with me per the article. There is some information that I think will find it very interesting about one of the least-known pieces of the ACA.

Absolutely wonderful commentary Dave, you are highlighting what is effectively the determining factor on the success of any treatment, solution or interaction whether analog or digital. In fact, by using means that interacts with individuals in a manner that ties to their particular lifestyle and to their particular needs drives engagement to dramatic and effective levels. Our experience in using personalized interactive mobile messaging has shown consistent engagement levels in the area 90% – 95% (meaning on-going use and satisfaction) to the benefit of both the patient and the provider.

Though the concept is not new, your perspective has brought this clearly to the fore and based on comments already creates a strong base on which to continue to the build on the insight and discussion.

Dave, thanks again for bringing attention to this issue and my article on HL7standards.com.

Related to Topol and Standards of Care: one issue Topol also brings up is how current Standards of Care, including statin prescriptions, are based on populations. Prescribing a single standard of care to the entire population when only a small part of the population receives benefit drives enormous costs in the system. The question in my mind, and I’m sure many physicians, is how we can move toward getting to a “standard of care” that’s more like a decision tree. We need to move toward more complex (or nuanced) standards as genomics and patient engagement become more commonplace to achieve the triple aim.

In regards to many current standards of care, there are billion$, if not trillion$ of reasons why they will be slow to change.

Excellent piece Dave & thanks Leonard! I totally agree that Patient Engagement is critical to achieving the Triple Aim. The fundamental underlying issue that needs to be addressed is accountability – at the consumer/patient/caregiver level & the Provider level. Until clear aligned roles are established and agreed upon and accountability for actions & inactions are taken seriously then the road to engagement will be fraught with HUGE challenges. @pjmachado

Great article David and great comments by Stephen Wilkins. Patient Engagement is a contact sport – and it going to require participation from all stakeholders (patients, providers, and payers), and, as with any sport, its going to require practice and on-going refinement – and taking the necessary time – to make sure we get it right. At its core, it is more about mind set – and doing the right thing/what makes sense/what works – than it is about technology which are only the tools that can hopefully facilitate better engagement.